TX HHS Form 3103. Cardiac Evaluation Report

The TX HHS Form 3103, Cardiac Evaluation Report, is a crucial tool for determining eligibility and developing rehabilitation plans for individuals with cardiac-related disabilities. This form helps solve the problem of identifying the best course of action for individuals seeking rehabilitation services due to cardiac conditions.

This report requires essential information such as birth date, social security number, telephone number, reported disability, reason for referral, and medical history. The medical history section includes details on the onset, duration, severity, and symptoms of the individual's cardiac condition, including factors like palpitations, dyspnea, peripheral edema, depression, anxiety, and other pertinent physical findings.

The Cardiac Evaluation Report is typically filled out by counselors or healthcare professionals who are working with individuals seeking rehabilitation services. By providing this information, they can better understand the individual's cardiac condition and develop an effective plan for their rehabilitation. Key points to note include:

• Required information includes birth date, social security number, telephone number, reported disability, reason for referral, and medical history.
• The report is used to determine eligibility and develop a plan for rehabilitation services.